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Sim lab F2015 > One Lung Ventilation/ Double Lumen Endotracheal Tube > Flashcards

One Lung Ventilation/ Double Lumen Endotracheal Tube Flashcards

1
Q

Indications for OLV

A
  1. Isolation of lung (absolute)
  2. Improved surgical access (relative)
  3. Control over ventilation (absolute) –> unilateral pulmonary lavage (washing of body cavity w water or medicated solution)
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2
Q

Who is a likely pt?

A

Elderly pts predisposed to CV disease as a result of smoking cigarettes for many yrs

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3
Q

What kind of tests should be conducted?

A
  • Those predictive of postop pulm. fxn
  • CT + X-rays to investigate possibility of airway obstruction in upper larynx, mid trachea, bronchial airways (as caused by tumors/masses)
  • Spirometry (post bronchodilator) + exercise data to predict preop risk + postop respir. reserve (i.e. pulm. fxn + risk of respir. failure)
  • Shuttle walk test: 4% = high risk; >25 shuttle or desat full cardiopulm. exercise testing
  • Cardiopulm. exercise testing: VO2max 15mL/kg/min = average risk
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4
Q

What is the predicted postop forced expiratory volume at 1s (ppo FEV1)?

A
  • FEV1 = max amt of air that can be forcibly expired in 1s –> provides insight into lung capacity
  • Can be estimated from total number segments in both lungs (19: 10 in R, 9 in L) + number to be resected (y)

ppo FEV1 = FEV1 x (19-y)/19

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5
Q

What is normal ppo FEV1?

A

FEV1 > 80%

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6
Q

Which main stem bronchi is shorter + wider?

A

Right - 2cm in length, 1.6cm in width

Left - 5cm in length, 1.3cm in width

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7
Q

Tracheobronchial dimensions are what percentage larger in men than in women?

A

20%

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8
Q

Which sided DLT is undesirable for many procedures requiring lung separation?

A

R-sided

  • L-sided DLT preferred b/c provides more uniform ventilation to all lobes
  • Short + variable length of R-sided DLT
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9
Q

What are the cons of using R-sided DLT?

A
  1. Must have precise positioning or else inadequate separation and/or collapse of upper R lobe
  2. May contain separate opening in bronchial lumen to permit ventilation of upper R lobe
  3. Malpositioning occurs >90% cases when using only physical examination
  4. Requires fiberoptic assessment to ascertain positioning
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10
Q

What are the indications for R-sided DLT?

A
  1. L mainstem bronchial mass (e.g. tumor)

2. L mainstem distortion (e.g. thoracic aneurysm)

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11
Q

List characteristics of DLT.

A
  1. 2 sep lumens: terminates in mainstem bronchi + distal trachea
  2. High vol, Low P cuffs
  3. Bronchial cuff = blue (facilitates fiberoptic visualization)
  4. Radiopaque markers to ID trachial + bronchial distal lumens
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12
Q

How are DLT sizes selected?

A

Women: 35-37 Fr
Men: 39 Fr

  • More precisely, can measure width of trachea using CXR
  • For every 10cm above 170cm at 1cm to tube depth
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13
Q

What is the technique for placing DLT?

A

General anesthesia w/ MR, MAC blade preferred

  1. Preoxygenate, induce anesthesia, DL
  2. Pass DLT w endobronchial lumen (longer) pointing up
  3. Insert tip thru cords until ET cuff passes cords
  4. Remove stylet
  5. Rotate tube 90 degrees in direction of appropriate lumen (L for L-sided, v.v.)
  6. Advance until resistance is felt, typically ~29cm for 170cm tall person
  7. Inflate cuffs + attach each lumen to circuit
  8. Confirm equal chest rise, =BBS, ETCO2
  9. Confirm proper placement of DLT
  10. Tape into position
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14
Q

How much air should you inflate to check integrity of DLT cuffs?

A

1-3ml for small cuff

5-10ml for large cuff

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15
Q

Do you need to apply lubricant to DLT?

A

Yes, to outside of tube

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16
Q

What are 3 ways to confirm proper placement of DLT?

A
  1. Functional confirmation
  2. Fiberoptic confirmation
  3. Bubble test
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17
Q

What is functional confirmation of DLT placement?

A
  1. Inflate cuffs
  2. Occlude opp lumen using soft-tipped airway clamp –> absent breath sounds over occluded side, and breath sounds on contralateral lung
  3. Repeat w/ other lung
  4. Check all lung fields to ensure tube not situated in segmental bronchus

Bronchial cuff should be inflated w 1-3ml
Tracheal cuff should be inflated w 5-10ml

18
Q

What is fiberoptic confirmation of DLT placement?

A
  1. FIRST: insert sm. diameter flexible bronchoscope into tracheal lumen
  2. Advance towards carina (visible ~2cm from end of ET lumen)
  3. Ascertain proper location of endobronchial lumen
  4. Gently inflate endobronchial cuff –> make sure doesn’t extend above carina –> herniate across + obstruct contralateral bronchus
  5. SECOND: insert bronchoscope into bronchial lumen
  6. Ascertain tube does not extend into segmental bronchus
  7. W R-sided tube, advance bronchoscope through side fenestration to ascertain alignment of orifice w R upper lobe bronchus (see pic)
19
Q

What is bubble test of DLT placement?

A

Used to confirm adequacy of bronchial lumen seal

  1. Inflate both cuffs
  2. Ventilate only bronchial lumen by occluding tracheal lumen w soft-tipped clamp
  3. Place one end of IV extension tubing into tracheal lumen + other end into into beaker of NS or water
  4. W +P breaths, no air should bubble through
20
Q

What is one problem that may occur while using DLT during positioning + surgery? How to reduce that?

A

DLT movement –> inadequate lung isolation
- Can help reduce problem of tube movement by using N2O as component of anesthetic + saline to inflate endobronchial cuff

21
Q

Emergence + extubation?

A
  1. Suction both lumens
  2. Carefully deflate cuffs
  3. Remove while giving +P breath
22
Q

What are contraindications of DLT?

A
  1. Pt refusal (absolute)
  2. Airway obstruction esp in larynx + trachea (absolute)
  3. Predicted diff w exchange of DLT w single lumen ET when ventilatory support is anticipated postop (relative)
  4. Diff/impossible DL (relative)
  5. Full stomach (relative) –> takes long time to place DLET
23
Q

What are possible complications of DLT?

A
  1. Hypoxemia, hypoventilation due to malpositioning
  2. Tracheobroncial tree disruption –> pneumothorax, subcutaneous emphysema
  3. Traumatic laryngitis
  4. Inadvertent suturing of DLT to bronchus
24
Q

If a pt has greater FEV1 >80% or >2L pneumonectomy, what testing does he need?

A

None

25
Q

If a pt has greater FEV1 >80% or >1.5L lobectomy, what testing does he need?

A

None

26
Q

If a pt has greater FEV1

A

Calculate ppo FEV1

27
Q

If a pt has greater FEV1

A

Det. DLCO (diffusion capacity for CO) + SaO2

28
Q

What values suggest high risk thoracic surgery?

A

ppo FEV1

29
Q

What values suggest average risk thoracic surgery, requiring no further testing?

A

ppo FEV1 >40% + DLCO>40% + SaO2>90%

30
Q

What are diff b/w R + L-sided DLET?

A

R-sided DLET have extra Murphy’s eye for ventilation of R upper lobe. Fiberoptic assessment required for proper positioning. Malpositioning is common in >90% cases using only physical examination.

31
Q

What is the Carlens tube?

A

L-sided DLET w carinal hook –> may be more likely to cause trauma to carina

32
Q

What are clinical signs of L bronchial lumen being too deep or bronchial cuff herniating over carina onto R main stem bronchus? How to fix?

A

Adequate ventilation of L bronchus but meet resistance w ventilation of R bronchus (tracheal lumen)

Repositioning of DLET using fiberoptic scope in tracheal lumen

33
Q

What are clinical signs of R main stem bronchus using L-sided DLET?

A

Ventilation through bronchial lumen results in R lung ventilation

Reposition DLET while turning pt’s head + neck to R while readvancing tube OR fiberoptic-guided repositioning

34
Q

Should you repeat fiberoptic bronchoscopy after positioning pt?

A

Yes, DLET may have moved. Esp. impt for R-sided DLET

35
Q

What can you do to aid in lung collapse?

A

Apply suction to nondependent lung

36
Q

How are pt usually positioned during thoracic surgeries requiring OLV? What kind of physiologic effects will this have on the lungs?

A

LLD. Lower lung = dependent; upper = nondependent. Dpt lung will have greater blood flow due to gravity but upper will have greater compliance (easier to ventilate), esp. once thoracic cavity is opened –> V/Q mismatch

OLV will lead to shunting of nondept lung (no ventilation w/ cont. blood flow)

37
Q

Which anesthetics directly or indirectly inhibits pulm. vasoconstriction?

A

Directly: volatile agents + direct vasodilators

Indirectly: vasoconstrictive drugs like norepi, which preferentially constrict vessels w NORMAL oxygen tension

38
Q

How does LLD affect V/Q changes?

A

Increases ventilation + decreases perfusion (20%) in nondependent lung. Decreases ventilation + increases perfusion (80%) in dependent lung.

39
Q

How to management hypoxia during OLV?

A
  1. Admin 100% O2
  2. Clear secretions from dept lung
  3. Check tube positioning
  4. Admin CPAP to nondept lung
  5. Perform recruitment maneuver/PEEP to dept lung
  6. Clamp nondept artery
  7. Return to 2 lung vent.

Don’t forget O2 sats WILL drop regardless b/c only 1 lung is ventilated.

40
Q

How can you provide CPAP to non-dependent lung?

A

You can provide flow-by oxygen to lungs attachment of tube to auxiliary O2 and inserted into bronchial port on attachment (bronchial tube remains clamped)

Sim lab F2015 (1 decks)

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